A SILENT THREAT

LARYNGEAL INVOLVEMENT IN PAGET’S DISEASE LEADING TO AIRWAY COMPROMISE

Abstract

INTRODUCTION/BACKGROUND

Paget’s disease of bone (PDB) is a chronic skeletal disorder characterized by disorganized bone remodelling, often affecting the skull, spine, pelvis and long bones. While complications such as fractures, arthritis and hearing loss are well-documented, laryngeal involvement leading to acute airway obstruction is exceptionally rare. To our knowledge, no previous case reports have described PDB affecting the thyroid and arytenoid cartilages, resulting in airway compromise.

CASE

A 45-year-old male with hypertension and eczema was diagnosed with a variant of PDB (normal alkaline phosphatase) in 2018, following an evaluation for right knee and ankle pain that began in 2016. Extensive investigations, including a bone biopsy, revealed nonspecific sclerosis, normal ALP, and mildly elevated bone formation markers (P1NP). A Tc-99m MDP bone scan showed multiple hot spots involving the skull, clavicles, ribs, L5, right elbow, both knees and both ankles. He was initiated on yearly intravenous zoledronate (4 mg). In 2022, he sustained a low-impact distal third right ulna fracture, necessitating a locking plate. The fracture site biopsy confirmed Paget’s disease.

In 2024, he presented with acute upper airway obstruction. A CT neck scan revealed expansile lytic lesions involving thyroid and arytenoid cartilages, causing significant airway narrowing. An emergency tracheostomy was performed to secure his airway. A repeated Tc-99m MDP bone scan demonstrated disease progression, with worsening involvement of the thyroid and cricoid cartilages.

CONCLUSION

This case highlights a rare and potentially fatal complication of PDB, with airway obstruction due to expansile lytic lesions of the laryngeal cartilages. Given the absence of prior reports on this manifestation, clinicians should remain vigilant for atypical presentations of PDB, particularly in patients with progressive disease. Early diagnosis and intervention are critical to preventing life-threatening outcomes.